Provider Demographics
NPI:1760821599
Name:ST JOSEPH'S DIAGNOSTIC CENTER LLC
Entity Type:Organization
Organization Name:ST JOSEPH'S DIAGNOSTIC CENTER LLC
Other - Org Name:BAYCARE OUTPATIENT IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:TAMBLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUBERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9390
Mailing Address - Street 1:2995 DREW STREET
Mailing Address - Street 2:EAST BLDG 2ND FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3800
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:10141 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7419
Practice Address - Country:US
Practice Address - Phone:813-554-8176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-14
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061048804Medicaid
FL061048804Medicaid